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Japan Journal of Nursing Science (2015) 12, 69–78
doi:10.1111/jjns.12049
ORIGINAL ARTICLE
Skin cancer knowledge and sun protection behavior among nursing students Medine YILMAZ,1 Betul YAVUZ,2 Media SUBASI,3 Asiye KARTAL,4 Aysun CELEBIOGLU,5 Halime KACAR,6 Filiz ADANA,7 Pakize OZYUREK8 and Saliha ALTIPARMAK9 1
Faculty of Health Sciences, Izmir Katip Celebi University, Cigli-Izmir, 2High School of Health, Dumlupinar University, Kutahya, 3Mugla High School of Health, Mugla University, Mugla, 4Denizli High School of Health, Department of Nursing, Pamukkale University, Denizli, 5Faculty of Nursing, Ege University, Bornova-Izmir, 6Usak High School of Health, Usak University, Usak, 7Aydin High School of Health, Adnan Menderes University, Aydin, 8High School of Health, Afyon Kocatepe University, Afyon and 9High School of Health, Celal Bayar University, Manisa, Turkey
Abstract Aim: The objective of this study was to determine skin cancer knowledge and sun protection behavior among nursing students. Methods: A total of 1178 nursing students in the Aegean Region of Turkey took part in this descriptive study. A score for knowledge on protection against skin cancer and a score for protective behavior against skin cancer were calculated. Results: In this study, first year students sunbathed more in the middle of the day than fourth year students, and their knowledge of skin cancer was lower. No statistical difference was determined for protective behavior between the two groups. The knowledge levels and protective behavior of first year students were alarmingly low, but the average scores for knowledge and behavior of the fourth year university students were higher. The knowledge levels of the fourth year students were average but their protective behavior was insufficient. It was found that the knowledge levels and the levels of protective behavior of light-skinned students were higher. Conclusion: This study revealed that the knowledge levels and protective behavior of first year nursing students against the harmful effects of the sun and for protection against skin cancer were alarmingly low. It also showed that the knowledge levels of the fourth year nursing students were average, but that their protective behavior was very insufficient. These findings suggest that it is of extreme importance to acquire knowledge and behavior for protection against skin cancers in the education of nursing students. Key words: nursing student, skin cancer, sun protection.
INTRODUCTION Skin cancer is a major health problem (Healthy People 2020 Guidelines; Mahon & Yackzan, 2010). Today,
Correspondence: Medine Yilmaz, Department of Public Health Nursing, Faculty of Health Sciences, Izmir Katip Celebi University, Balatcik Campus, 35620, Çig˘li, Izmir, Turkey. Email: [email protected] Received 10 September 2013; accepted 4 February 2014.
people are exposed more to intensive ultraviolet (UV) rays than in the past with the popularity of tanning in recent years; people spend an excessive amount of time under the sun during seaside vacations and in participating in outdoor sports; new technology has meant an increase in industrial equipment emitting UV rays; and the hole in the protective ozone layer has increased in size. This increased exposure to UV radiation may be one of the biggest factors contributing to the rise in the incidence of skin cancer (Mahon & Yackzan, 2010).
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
M. Yilmaz et al.
Japan Journal of Nursing Science (2015) 12, 69–78
Studies have been made in many countries to determine the effect of the sun’s rays on the skin in various segments of society, the levels of knowledge and awareness on the subject of skin cancers, and behavior for protection against the sun (Nikolaou et al., 2009; Saridi et al., 2009; Stanton, Janda, Baade, & Anderson, 2004). Furthermore, many types of media and educational campaigns have been carried out with the objective of preventing the development of skin cancers (Geller et al., 2002; Saraiya et al., 2003; Vries, Lezwijn, Hol & Honing 2005). Primary and secondary prevention are essential components of the effort to decrease mortality and morbidity risk from these malignancies. The total of all skin cancers can be decreased by 80% with suitable protective measures taken from an early age (Saraiya et al., 2003). The Healthy People 2020 Guidelines aims to “increase the proportion of persons who participate in behaviors that reduce their exposure to harmful ultraviolet (UV) irradiation and avoid sunburn”. The Healthy People 2020 Guidelines pointed to an increase in the proportion of people using skin cancer primary prevention strategies, which include at least one of the following protective measures: avoiding the sun between 10.00 and 16.00 hours, wearing sun-protective clothing, using sunscreen with a sun protection factor (SPF) of 15 or higher, and decreasing or avoiding UV radiation exposure (Healthy People 2020 Guidelines). Just as early detection of skin cancer and screening are important, taking individual protective measures are also extremely important (Mahon & Yackzan, 2010). The personalization of these measures according to age, sex, and educational status is important (Stanton et al., 2004). Intelligent strategies should be also developed for changing the belief and perception that having a tanned skin is desirable (Nikolaou et al., 2008; Saridi et al., 2009). Training individuals on protection against the harmful effects of the sun’s rays, changing stereotyped behavior, and transforming information into behavior are of extreme importance. Nurses can influence the public to practice primary and secondary prevention strategies (Mahon & Yackzan, 2010; Tidy, 2003). It is inevitable that nurses, who have an effective role in health protection, should also be included in education and campaigns against skin cancer. Therefore, acquiring the knowledge and skills to change behavior in relation to skin cancers is relevant to the education of nurses. In a Greek study including nurses, women were found to use sunglasses and sunscreen more than men and age was also found to affect the use of protective measures
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with those aged between 30 and 50 years found to use an umbrella/shade and clothing to protect themselves from sun exposure more than those younger than 30 years (Brokalaki et al., 2011). In other study (Ermertcan et al., 2005), use of sunscreen and sunglasses in men over 30–40 years of age were significantly higher in doctors and nurses (52.7% and 50.5%, respectively) than medical and nursing students. It was found that incomplete information about protective measures, especially using sunscreen and wearing protective clothing and a hat. Ermertcan et al. (2005) suggest that an efficient policy of education on the effective use of sun protection methods beginning in childhood and adolescence should be developed to prevent skin cancer. The Aegean Region of Turkey has a typical sunny Mediterranean climate. This region benefits greatly from the sun and is exposed to sunlight for 9 months a year. Consequently, it is important to determine the knowledge levels and protective behavior against the effects of the sun and protection against skin cancers of nursing students born or living in this region. The objective of this study was to determine the skin cancer knowledge and sun protection behavior among nursing students. In accordance with this objective, the study questions directed to the first and fourth year university students were as follows: 1 Is there a difference between the groups (first and fourth year nursing students) in their knowledge level scores for protection against the sun and skin cancer? 2 Is there a difference between the groups in their protective behavior scores for protection against the sun and skin cancer?
METHODS Sample and setting This descriptive study was carried out between September 2012 and February 2013. In Turkey, nursing schools are faculties directly connected to a university. Nursing education involves a 4 year (eight semester) bachelor degree program in a university. Each semester, the students register in one main professional nursing course and in the second semester they attend a clinical practice course in addition to their theoretical courses. The research was conducted among students of eight nursing colleges in cities in the Aegean Region of Turkey (n = 1625). No sampling method was used in the study, because the study included the whole adolescent and youth population of the selected university (n = 1178) (Table 1). The ratio of participation was 72.8% for the first year students and 72.1% for the fourth year
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 69–78
Skin cancer and nursing students
Table 1 Name, location of nursing school and number of students in Aegean Region University
Location
Grade 1
Grade 4
City Urban Urban Urban Urban Urban City City
99 101 108 96 51 104 49 68 676
65 80 87 48 26 96 44 56 502
Denizli Manisa Kütahya Us¸ak Afyon Mug˘la Aydin I˙zmir Total
Pilot application in 20 nursing students June 2012 Data collection September 2012–February 2013 Universe 1625 students (Total eight school of nursing in Agean Region) Inclusion criteria Willingness of students - Attainability to students Sample 1178 students (The rate of participation) 1st Grade d 676 students
4th Grade 502 students
Questionnaire Q (Sociodemographic characteristics, Knowledge and Behavior Questions)
Figure 1 Design of study.
students. The criteria for inclusion were being a university student of the nursing and being willing to take part in the study (Fig. 1). The majority of students (37.4%) were born in a city in the Aegean Region, 14.8% in the Mediterranean Region and 14.4% in the Black Sea Region.
Data collection The data were collected by the researchers between September and December in the academic year 2012–2013. They were contacted directly in their classroom. Detailed information was given to the students about the research and verbal consent was obtained. The ques-
tionnaires were distributed to students in their classroom. It took approximately 20 min to fill out a survey in a single session. After the students filled out the questionnaires in the classroom, the questionnaires were collected by researchers in a box.
Instruments The survey instrument was a questionnaire developed to determine knowledge and behavior, and was based on the current published work (Brokalaki et al., 2011; Devos, Baeyens, & Van Hecke, 2003; Ermertcan et al., 2005; Hedges & Scriveni, 2010; Miles, Waller, Hiom, & Swanston, 2005; Nikolaou et al., 2009; Saridi et al., 2009; Stanton et al., 2004). After determining the questions, the expert opinions of one dermatologist, three academician nurses and two dermatology nurses were obtained. In June 2012, subsequently, a pilot application was conducted with 20 young nursing students of the same age who were not participating in the study. The final questionnaire included four parts, with 17 questions relating to sociodemographic characteristics, 10 questions about behavior for protection against the sun, 14 questions relating to the risk factors of skin cancer, and 18 questions about knowledge of skin cancers and methods of protecting against the sun. In addition, questions were asked about familial skin cancer, experiences of sunburn, sources of knowledge, tanning behavior and use of SPF. The skin types of the students were grouped according to the Fitzpatrick classification: skin “burns” without or with minimal tanning (phototype I and II), “burns” and then tans (phototype III) or tans easily without burning (phototype IV) (Nikolaou et al., 2009).
Knowledge level score for protection against skin cancer The knowledge level for the etiopathogenesis of skin cancers and methods of protection against the sun was examined in 15 questions and the results were obtained by adding 1 point for each of the correct responses (0 points were given for “wrong/I do not know” answers and 1 point was given for correct answers). The knowledge level score was formed by adding all the scores together. The knowledge scores ranged 0 (minimum) to 15 (maximum).
Behavior score for protection against the sun and skin cancer Points were given according to the frequency of implementation of each of the methods applied for protection
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
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Japan Journal of Nursing Science (2015) 12, 69–78
Permission was obtained from the ethics committee of the university (ethic no: 26) where the research coordinatorship was located in order to carry out the study. Verbal permission was obtained from the nursing universities where the study was carried out and verbal approval was obtained from the students. Students’ names were not used.
anova – were used, in addition to descriptive statistics given in numbers and percentages. Number and percentage distributions of the sociodemographic characteristics of the students and the frequencies of protective practices were compiled. In the determination of the average scores for protective behavior, the responses of the students for each item were rated in the form of “always”, “frequently”, “sometimes/rarely” and “never” and were evaluated between 1 and 4 points. When a student’s score approached 4, it was interpreted that protective measures were being taken, and when it approached 1, it was interpreted that protective measures were not being taken. In addition, a relationship was sought between the sociodemographic variables of the students and their scores for protective behavior, knowledge levels and risk factors. Cronbach’s alpha was 0.72 (moderate = 0.60–0.80) (Ozdamar, 2002).
Statistical analysis
FINDINGS
against the sun and were evaluated on a 4 point scale (“never” = 1, “sometimes” = 2, “frequently” = 3 and “always” = 4). The total points obtained were divided by the number of 13 items, to calculate the behavior score for protection against the sun and skin cancer. For the calculation of the total score, a minimum of eight responses to the 13 protective behavior patterns was needed (minimum 13, maximum 52 points).
Ethical implementations
The data were evaluated with IBM Predictive Analytics SoftWare (PASW) Statistical Product and Service Solutions (SPSS, Chicago, IL, USA) version 20.0. In the evaluation of the data obtained in the study, statistical significance tests – non-parametrical tests such as the χ2-test, standard deviation, Student’s t-test and one-way
Demographics and skin characteristics The sociodemographic characteristics of the students are given in Table 2. A majority of both the first year and fourth year students were female (first year, 78.6%; fourth year, 54.1%). The students were mostly fair
Table 2 Sociodemographic characteristics of nursing university students and their risk factors for skin cancer Characteristics Mean age, years Sex Female Male Color of skin Light-skinned Fair-skinned Dark-skinned Photo type I–II III–IV Color of hair Blonde–auburn Dark brown/black Common nevi I have never counted ≤5 6–10 11–20 >20 Total †
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Grade 1
Grade 4
χ2
P
5.04
0.002
19.2 ± 1.2 n %† 531 78.6 145 21.4
n 366 136
22.4 ± 1.4 %† 54.1 45.9
474 371 202
15.2 54.9 29.9
87 294 121
17.3 58.6 24.1
4.98
0.83
424 252
62.7 37.3
307 195
61.2 38.9
9.72
0.008
220 456
32.5 67.5
188 314
37.5 62.5
3.06
0.80
351 124 60 65 76 676
52.0 18.3 8.9 9.6 11.2 57.4
225 96 63 52 66 502
44.8 19.1 12.5 10.4 13.2 42.6
7.81
0.09
The percentage of rows.
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 69–78
Skin cancer and nursing students
Table 3 Distribution of nursing students’ knowledge about sun protection and skin cancer prevention Grade 1 Characteristics
n
Knowledge status of skin cancer Do not know 402 Know 274 Knowledge of protection from skin cancer Do not know 187 Yes, I know 102 I know a bit 387 Perception of skin cancer risk in future High 29 Moderate 113 At average 257 I do not know 277 Source of information† From the lessons 92 From the clinical practice course 46 From the health profession 26 From the media (e.g. Internet, TV) 175 From family or friends 83 †
Grade 4
%
n
%
χ2
p
59.5 40.5
170 332
33.9 66.1
75.59
0.000
27.7 15.1 57.2
76 169 257
15.1 33.7 51.2
65.38
0.000
4.3 16.7 38.0 41.0
23 110 211 158
4.6 21.9 42.0 31.5
12.37
0.006
13.6 6.8 3.8 25.9 12.3
233 94 57 269 61
46.4 18.7 11.3 53.6 12.1
There is possibility of marking multiple choices in this question.
skinned (first year, 54.9%; fourth year, 58.6%) and had dark brown or black hair (first year, 67.5%; fourth year, 62.5%). The proportion of phototype I–II in the first year students was higher than in the fourth year students (χ2 = 9.72, P = 0.008). A large proportion of the students in both years (first year, 52%; fourth year, 44.8%) did not know the number of moles on their bodies (Table 2).
Knowledge level for protection against the sun and skin cancer It was determined that 59.5% of the first year students did not know about skin cancers but that 66.1% of the fourth year students knew about skin cancers (χ2 = 75.59, P = 0.000) (Table 3). It was found that the first three sources of knowledge for the first year students were media tools at 25.9%, lessons at 13.6% and friends and family at 12.3%, while for the fourth year students the first three sources of knowledge were media tools at 53.6%, lessons at 46.4% and clinical practice course at 18.7% (Table 3). It was determined that in answer to the question about knowing how to protect against skin cancer, 57.2% of the first year students responded “I know a bit”, 51.2% of the fourth year students responded “I know a bit” and 33.7%
responded “Yes, I know”; and there was a significant difference between the two groups in knowing how to protect against skin cancer (χ2 = 65.38, P = 0.000) (Table 3). For perceiving the risk of having skin cancer in the future, 41% of the first year students stated “I do not know”. The response of the fourth year students was average or less than average at 31.5%. A statistically significant difference was determined for perceiving risk between the two groups (χ2 = 12.37; P = 0.006) (Table 3). It was observed that the average scores for knowledge (t = 10.13, P = 0.000) and behavior (t = 4.48, P = 0.000) for protection against the sun and skin cancer of the fourth year students (knowledge, 7.6 ± 2.9; behavior, 9.4 ± 2.8) were higher than those of the first year students (knowledge, 2.5 ± 0.4; behavior, 2.6 ± 0.4). A statistically significant difference was determined between the average scores of the two groups (Table 4).
Behavior for protection against the sun and skin cancer It was determined that 64.4% of the first year students sunbathed more in the noon hours, compared to 35.6%
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
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Japan Journal of Nursing Science (2015) 12, 69–78
Table 4 Distribution of students’ mean scores of knowledge, behavior and attitude about sun protection and skin cancer prevention Scores Knowledge (15 questions) Behaviors (13 questions)† †
Grade 1, n/% 676 676
Grade 4, n/%
7.6 ± 2.9 2.5 ± 0.4
502 502
9.4 ± 2.8 2.6 ± 0.4
t
P
10.13 4.48
0.000 0.000
1 = never, 4 = always.
Table 5 Distribution of nursing university students’ behavior about sun protection Characteristics
Grade 1, n/%
χ2
P
44.2 35.6
5.38
0.02
66.1 33.9
0.19
0.66
15.3 32.4 15.9 36.5
8.53
0.03
57.4 42.6
2.72
0.09
36.0 64.0
2.27
0.13
84.9 15.1
1.60
0.20
Grade 4, n/%
Sunbathing in noon hours No 535 55.8 424 Yes 141 64.4 78 Tanning No 458 67.7 332 Yes 218 32.3 170 Sunbathing time (n = 218) Day long 33 15.1 26 09.00–11.00 hours 55 25.2 55 11.00–16.00 hours 61 28.0 27 After 16.00 hours 69 31.7 62 Use of sun-protective factors No 420 62.1 288 Yes (>15 SPF) 256 37.9 214 Experience of slight sunburn (in their lifetime) Never 273 40.4 181 Minimum, once 403 59.6 321 Experience of 3–4 degree sunburn (in their lifetime) Never 591 87.4 426 Minimum, once 85 12.6 76 SPF, skin protection factor.
of the fourth year students (χ2 = 5.38, P = 0.02). It was observed that 32.3% of the first year students and 33.9% of the fourth year students sunbathed to get a tan, and that the first year students did this mostly between 11.00 and 16.00 hours and after 16.00 hours, while the fourth year students sunbathed to get a tan between 09.00 and 11.00 hours and after 16.00 hours (χ2 = 8.53, P = 0.03). A large proportion of the students in both years of study did not use sun protectors (first year, 62.1%; fourth year, 57.4%) and it was observed that the difference between the two groups was not significant (P > 0.05) (Table 5). A total of 59.6% of the first year students and 64% of the fourth year students had experienced slight sunburn at least once and 13.8% (first year 12.6%, fourth year 15.1%) had experienced third to fourth degree sunburn at least once (P > 0.05) (Table 5). The fourth year students used sunglasses at a higher ratio (χ2 = 8.89, P = 0.03). Other than this,
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no statistically significant difference was determined between the two groups for protective behavior (P > 0.05) (Table 6). The genetic characteristics and knowledge, behavior, and attitude scores of all students were examined. It was found that light-skinned students showed more protective behavior than those with dark skins (2.65 ± 0.49 and 2.15 ± 0.52, respectively) (F = 6.19, P = 0.000), and that their scores on knowledge of protection against the sun were higher (8.77 ± 3.0 and 8.07 ± 3.0, respectively) (F = 3.55, P = 0.000). Similarly, it was found that those of phototype I/II (light-skinned) (I, 2.65 ± 0.4; II, 2.55 ± 0.4) showed greater protective behavior than those of phototype III/IV (dark-skinned) (I, 2.58 ± 0.4; II, 2.41 ± 0.4) (F = 6.01, P = 0.00). It was observed that those with light hair showed more protective behavior (light hair, 2.63 ± 0.4; dark brown, 2.58 ± 0.4; black, 2.46 ± 0.4) (F = 11.45, P = 0.000), and that their
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 69–78
Skin cancer and nursing students
Table 6 Distribution of nursing university students’ behavior about sun protection and skin cancer prevention Protective behavior Using a cap Staying in the shade Use of sunglasses Tanning at the beach Using an umbrella Clothing, long-sleeves †
Grade
Never, n (%)†
Occasionally, n (%)†
Often, n (%)†
Always, n (%)†
1 4 1 4 1 4 1 4 1 4 1 4
422 (62.4) 317 (63.1) 27 (4.0) 12 (2.4) 225 (33.3) 146 (29.1) 352 (52.1) 251 (51.0) 484 (71.6) 344 (68.5) 140 (20.7) 90 (17.9)
213 (31.5) 119 (27.7) 99 (14.6) 63 (12.5) 231 (34.2) 154 (30.7) 179 (26.5) 129 (25.7) 107 (15.8) 8 (17.5) 329 (48.7) 244 (48.6)
24 (3.6) 33 (6.6) 281 (41.6) 231 (46.0) 142 (21.0) 119 (23.7) 63 (9.3) 61 (12.2) 50 (7.4) 45 (9.0) 100 (14.8) 86 (17.1)
17 (2.5) 13 (2.6) 269 (39.8) 196 (39.0) 78 (11.5) 83 (16.5) 82 (12.2) 61 (12.1) 35 (5.2) 25 (5.0) 106 (15.8) 82 (16.3)
χ2
P
6.87
0.07
4.50
0.21
8.89
0.03
2.50
0.47
1.79
0.61
2.31
0.67
Percentage of rows.
knowledge scores were higher (light hair, 8.72 ± 3.1; dark brown, 8.45 ± 2,9; black, 8.01 ± 3.1) (F = 6.42, P = 0.002).
DISCUSSION The main known cause of skin cancers is exposure to sunlight. Turkey is a Mediterranean country located between the temperate zone and subtropical zone and is a country with abundant sunlight. Despite this intensive exposure to the sun’s rays, there are still no societal initiatives for protection against the effects on health of the sun and against skin cancers, such as exist in the other European countries (Geller et al., 2002; Saraiya et al., 2003; Vries, de Lezwijn, Hol, & Honing, 2005). Not much is known, however, about the behavior, attitude, and perceptions of adolescents and young people on the subject of exposure to the sun and its associated risks. This study has shown the need for eliminating the lack of knowledge on protection against skin cancers in the curricula as a course in one semester or to take place in the lessons of nursing students, who will be responsible for the care of individuals in the society in the future, and the need for giving more place in education to the skills of acquiring protective attitudes and behavior such as wearing sun-protective clothing and sunglasses, and using sunscreen with an SPF. Phenotypic individual risk factors, such as hair, skin and eye color, are directly related to sensitivity to UV radiation. Persons with a light or fair complexion have a tendency to freckle or burn easily and are at higher risk (Brokalaki et al., 2011; Mahon & Yackzan, 2010; Nikolaou et al., 2009). A large proportion of the students in the study had dark brown or black hair. This is
an advantage against the effects of sunlight. Nevertheless, the first year students were mainly light-skinned (phototype I–II), which shows that this group had a greater risk. Widespread exposure to the sun causes an increase in moles, and the number of melanocytic moles is correlated with risk (Mahon & Yackzan, 2010). It was observed that a large proportion of the students in both years did not know the number of moles on their bodies and did not perform self-examination for the early determination of skin cancers. In other studies, just as in this study, it was determined that nurses (Brokalaki et al., 2011) and adolescents (Saridi et al., 2009) had similar numbers of moles and did not self-examine their moles. If skin cancer is detected early, its treatment is facilitated. Therefore, personal skin examination is important for early diagnosis (Tidy, 2003). It is important to acquire the skill of self-examination in future training activities for adolescents and young people. It has been reported in other studies that protection is of primary importance for decreasing the exposure to the major risk factors for skin cancers. One of the key preventive measures is to stay in the shade during the peak hours of the day (Mahon & Yackzan, 2010; Saraiya et al., 2003). The present study draws attention to the fact that approximately one third of the students in both years sunbathed to get a tan. Besides, the first year students preferred to sunbathe between 10.00 and 16.00 hours and showed riskier behavior. In fact, in studies made with different samplings (Brokalaki et al., 2011; Nikolaou et al., 2009; Saridi et al., 2009), it was observed that individuals also sunbathed at risky hours and that the incidence of sunbathing was similar or even higher.
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
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Those who experience a serious degree of sunburn before the age of 18 years at risk of developing melanoma, which is the most serious cancer type (Saridi et al., 2009). According to the conclusion of one study, the belief that it is necessary to burn to get a tan prevents the use of protection, and this also coincides with more frequent sunburns (Geller et al., 2002). That the fourth year students experienced slight and severe sunburn at a higher rate than the first year students shows that this group was exposed to greater risk. The ratio of sunburn experiences of the students in both groups are close to the results in various other studies (Geller et al., 2002; Vries et al., 2005) and are higher than in some others (Brokalaki et al., 2011; Turgay, Sari, Can, & Ekti Genc, 2005). The Healthy People 2020 Guidelines has announced the aim of increasing the proportion of adults aged 18 years and older who follow protective measures to reduce the risk of skin cancer (Healthy People 2020 Guidelines). The three methods of protection implemented the most frequently are staying in the shade (Brokalaki et al., 2011; Devos et al., 2003; Ermertcan et al., 2005; Uslu, Karaman, Savk, & Sendur, 2006; Vries et al., 2005), the use of protective clothing (Devos et al., 2003; Vries et al., 2005) and the use of sunglasses (Brokalaki et al., 2011; Ermertcan et al., 2005; Uslu et al., 2006). Just as in another study made in Turkey (Ermertcan et al., 2005), this study showed that the risk of sun exposure is largely unrecognized in the Aegean Region of Turkey, and nursing students have very inadequate information and behavior concerning protective measures. The use of sun protection in the students in both years was very low. While this result was similar to the results of some studies (Devos et al., 2003; Ermertcan et al., 2005; Geller et al., 2002; Saridi et al., 2009; Spradlin, Bass, Hyman, & Rosanne, 2010), it was low compared to studies conducted in Greece (90%) (Nikolaou et al., 2009) and Malta (51%) (Scerri, Aquilina, Amato, & Dalmas, 2002). Other than the fourth year students using sunglasses more, the protective measures in both groups were very insufficient, and no difference was observed between the two groups of students. In a study conducted on persons between the ages of 16 and 65 years, it was determined that the use of protection and general protective behavior were the lowest in persons between 16 and 24 years of age (Weinstock, Rossi, Redding & Maddock, 2000). Geller et al. (2002) reported an increase in behavior for protection against the sun in students between 15 and 18 years of age when the topic of skin cancer was added to school curricula. In Turkey, there is no formal lesson
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on the curriculum of nursing schools on health protection and development, and is generally given little coverage in the content of lessons on protection from cancer. Teaching protective measures should be given to students in a lesson including health promotion issues such as cancer epidemiology, health promotion strategies, early diagnosis and medical–surgical nursing from the first grade to fourth grade. These educational sessions should be given by interactive methods to increase awareness. It must be determined whether behaviors change by long-term follow up. If behavior change has not occurred during this process in students at risk, counseling should be given to take individual protective measures. Some messages can be specifically targeted at students at risk. If these messages are given by peers, it can have a positive influence on an student’s sun safety habits. In studies made in various countries (Hedges & Scriveni, 2010; Miles et al., 2005), it was reported that the knowledge of participants of the risks of exposure to sunlight and of protective measures was at a medium to high level. In the present study, half or more than half of the students in both years did not know the types of skin cancer and how to protect against them. In a study conducted in Greece (Nikolaou et al., 2009), it was determined that a majority of the participants knew that exposure to the sun was a cause of skin cancer, but that this was not known by those younger than 34 years of age. It was reported that Greek adolescents between 15 and 18 years of age (Saridi et al., 2009) had both insufficient knowledge and also displayed risky behavior during the summer months. In this study, despite the fact that the average knowledge scores of the fourth year students were higher than those of the first year students, if it is considered that the students at this year level have received professional education, then it can be stated that their levels of knowledge and ratios of showing protective behavior were very low. This conclusion shows that besides adding knowledge to nursing education curricula, the need for acquisition of positive behavioral changes must be addressed. In the future, comprehensive studies can be designed. Studies made in various countries (Hedges & Scriveni, 2010; Saridi et al., 2009) show that television and family are the most important sources of knowledge and, in fact, for the students in this study, media tools (Internet, newspapers, TV) were in first place. The fact that the media was used frequently as a source of knowledge in both groups shows that it is an effective tool in reaching all segments of society with awareness and educational campaigns. Nevertheless, it is thought-
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 69–78
provoking that the level of the use of classes and professional practice as a source of knowledge by fourth year students throughout their university education was very low. A differentiation was observed between the first and fourth year students on the perception of the risk of skin cancer in the future. While the first year students did not know the risk (41%), the fourth year students saw it as a less than average risk (42%). It has been reported that those who consider themselves at risk for skin cancer and those who have skin which is sensitive to the sun take more protective measures against exposure to sunlight (Abroms, Jorgensen, Sothwell, Geller, & Emmons, 2003). Studies by Stanton et al. (2004) and Vries et al. (2005) show that those who consider themselves to be at risk use more protective measures. However, it was found in this study that protective behavior and knowledge levels about skin cancer in students who did not see themselves as being at risk of skin cancer in the future was low, and that there was no relationship between those who considered themselves to be at high risk and the use of protective measures. It was also observed that the use of protective measures was also slight in those who did not foresee or did not know the risk. According to a study by Fangchao, Collado-Mesa, Hu, Kirsner (2007), it can be stated that the perception of the risk of skin cancer in Turkish adolescents and young people is lower than the risk perception of people in other countries. There were some limitations of this study. The moles were not counted by a health professional and the numbers were recorded according to the student’s memory. Another limitation is that the students answered “I know” or “I do not know” with a statement about skin cancer, a fact lead to an overestimation of the proportion of students who have a true knowledge of skin cancer. The study population was nonrandomized. Finally, the sample included only nursing students in the Aegean Region of Turkey. Studies should be carried out to show data for all Turkey’s regions’ nursing students.
CONCLUSION The conclusion of this study revealed that the knowledge levels and protective behavior of first year university students against the harmful effects of the sun and for protection against skin cancer were alarmingly low. Additionally, it also showed that the knowledge levels of the fourth year university students were average, but that their protective behavior was very insufficient. Con-
Skin cancer and nursing students
sequently, it is of extreme importance to acquire knowledge and behavior about the harmful effects of the sun, and for the education of nursing students in protection against skin cancer, who will act as role models and who will take an active role in the protection and maintenance of the health of individuals. To make the Healthy People 2020 Guidelines into a reality, increased efforts to implement primary, secondary and tertiary skin cancer prevention are needed. Sun-safe behavior should be greatly encouraged. Implementation for developing competent nursing graduates should be strengthened. Finally, faculty development and integration of clinical practice guideline to the schools program of study may be warranted. Putting educational programs into practice will help to decrease the risk of skin cancers in children and young people in the future and contribute to the acquisition of protective behavior and attitudes.
CONFLICT OF INTEREST No conflict of interest has been declared by the authors.
REFERENCES Abroms, L., Jorgensen, C. M., Sothwell, B. G., Geller, A. C. & Emmons, K. M. (2003). Gender differences in young adults’ beliefs about sunscreen use. Health Education & Behaviour, 30, 29–43. Brokalaki, H., Patelarou, E., Vardavas, C., Elefsiniotis, I. S., Giakoumidakis, K. A. & Brokolaki, E. (2011). Current patterns of the sun protection measures adopted by nurses and the risk factors influencing their compliance. Open Journal of Nursing, 1, 43–50. Devos, S. A., Baeyens, K. & Van Hecke, L. (2003). Sunscreen use and skin protection behavior on the Belgian beach. International Journal of Dermatology, 42, 352–356. Ermertcan, A. T., Öztürkcan, S., Dinç, G., Yurtman, D., Pala, T. & Sahin, M. T. (2005). Sun screen use and sun protection practices in students and personnel of Celal Bayar University. Photodermatology, Photoimmunology & Photomedicine, 21, 191–197. Fangchao, M., Collado-Mesa, F., Hu, S. & Kirsner, R. S. (2007). Skin cancer awareness and sun protection behaviors in white Hispanic and white Non-Hispanic high school students in Miami, Florida. Archives of Dermatology, 143, 983–988. Geller, A. C., Colditz, G., Oliveria, S., Emmons, K., Jorgensen, C., Aweh, G. N. et al. (2002). Use of sunscreen, sun burning rates, and tanning bed use among more than 10 000 us children and adolescents. Pediatrics, 6, 1009– 1014. Healthy People 2020 Guidelines. [Cited 4 August 2012.] Available from URL: http://www.healthypeople.gov/2020/ topicsobjectives2020/objectiveslist.aspx?topicId=5.
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Hedges, T. & Scriveni, A. (2010). Young Park Users’ Attitudes And Behaviour To Sun Protection. Global Health Promotion, 17, 24–31. Mahon, S. M. & Yackzan, S. G. (2010). Skin cancer. In: C. H. Yarbro, D. Wujak & B. H. Gobel (Eds), Cancer Nursing: Principles and Practices (7th edn). pp. 1651–1682). Sadburg, MA: Jones and Barlett Publishers. Miles, A., Waller, J., Hiom, S. & Swanston, D. (2005). Sunsmart? Skin cancer knowledge and preventative behaviour in a British population representative sample. Health Education Research, 20, 579–585. Nikolaou, V., Stratigos, A. J., Antoniou, C., Sypsa, V., Avgerinou, G., Danopolou, I. et al. (2009). Sun exposure behavior and protection practices in a mediterranean population: A questionnaire-based study. Photodermatology, Photoimmunology & Photomedicine, 25, 132–137. Nikolaou, V. A., Sypsa, V., Stefanaki, I., Gogas, H., Papadopoulos, D., Plaka, M et al. (2008). Risk associations of melanoma in a Southern European population: Results of a case/control study. Cancer Causes & Control, 19, 671–679. Ozdamar, K. (2002). Statistical Data Analysis with Packages Programmes (Paket Programlar ile I˙statistiksel Veri Analizi) (4th edn). Eskis¸ehir: Kaan Press.pp. 661–673). Saraiya, M., Glanz, K., Briss, P., Nichols, P., White, C. & Das, D. (2003). Preventing skin cancer: Findings of the task force On community preventive services on reducing exposure to ultraviolet light. MMWR CDC Recommendations and Reports, 52, 1–12. Saridi, M., Pappa, V., Kyriazis, I., Toska, A., Giolis, A., Liachapoulou, A. et al. (2009). Knowledge and attitudes to sun exposure among adolescents in Korinthos, Greece. Rural and Remote Health, 9, 1162.
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Scerri, L., Aquilina, S., Amato, G. A. & Dalmas, M. (2002). Sun awareness and sun protection practices in Malta. Journal of European Academic Dermatology and Venereology, 16, 47–52. Spradlin, K., Bass, M., Hyman, W. & Rosanne, K. (2010). Skin cancer: Knowledge, behaviors, and attitudes of college students. Southern Medical Journal, 103, 999– 1003. Stanton, W. R., Janda, M., Baade, P. D. & Anderson, P. (2004). Primary prevention of skin cancer: A review of sun protection in Australia and internationally. Health Promotion International, 19, 369–378. Tidy, N. (2003). Keeping skin safe from the harmful effects of UV rays. Primary Health Care, 13, 32–34. Turgay, A. S., Sari, D., Can, M. & Ekti Genc, R. (2005). Determination of sunburn and skin cancer risk of outpatients in a dermatology polyclinic. Asian Pacific Journal of Cancer Prevention, 6, 143–146. Uslu, M., Karaman, G., Savk, E. & Sendur, N. (2006). Adnan Menderes Üniversitesi hekimlerinin deri kanserleri ve günesin etkileri konusundaki bilgi düzeyleri ile günesten korunma davranislarinin deg˘erlendirilmesi. Journal of Adnan Menderes University Faculty of Medicine (Adnan Menderes Universitesi Tip Fakültesi Dergisi, 7, 5 – 10. (in Turkish). Vries, H., de Lezwijn, J., Hol, M. & Honing, C. (2005). Skin cancer prevention: Behaviour and motives of Dutch adolescents. Eur J Cancer Prevent, 14, 39–50. Weinstock, M. A., Rossi, J. S., Redding, C. A. & Maddock, S. D. (2000). Sun protection behaviors and stages of change for the primary prevention of skin cancers among beachgoers in Southeastern New England. Annual Behavioural Medicine, 22, 286–293.
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doi:10.1111/jjns.12049
ORIGINAL ARTICLE
Skin cancer knowledge and sun protection behavior among nursing students Medine YILMAZ,1 Betul YAVUZ,2 Media SUBASI,3 Asiye KARTAL,4 Aysun CELEBIOGLU,5 Halime KACAR,6 Filiz ADANA,7 Pakize OZYUREK8 and Saliha ALTIPARMAK9 1
Faculty of Health Sciences, Izmir Katip Celebi University, Cigli-Izmir, 2High School of Health, Dumlupinar University, Kutahya, 3Mugla High School of Health, Mugla University, Mugla, 4Denizli High School of Health, Department of Nursing, Pamukkale University, Denizli, 5Faculty of Nursing, Ege University, Bornova-Izmir, 6Usak High School of Health, Usak University, Usak, 7Aydin High School of Health, Adnan Menderes University, Aydin, 8High School of Health, Afyon Kocatepe University, Afyon and 9High School of Health, Celal Bayar University, Manisa, Turkey
Abstract Aim: The objective of this study was to determine skin cancer knowledge and sun protection behavior among nursing students. Methods: A total of 1178 nursing students in the Aegean Region of Turkey took part in this descriptive study. A score for knowledge on protection against skin cancer and a score for protective behavior against skin cancer were calculated. Results: In this study, first year students sunbathed more in the middle of the day than fourth year students, and their knowledge of skin cancer was lower. No statistical difference was determined for protective behavior between the two groups. The knowledge levels and protective behavior of first year students were alarmingly low, but the average scores for knowledge and behavior of the fourth year university students were higher. The knowledge levels of the fourth year students were average but their protective behavior was insufficient. It was found that the knowledge levels and the levels of protective behavior of light-skinned students were higher. Conclusion: This study revealed that the knowledge levels and protective behavior of first year nursing students against the harmful effects of the sun and for protection against skin cancer were alarmingly low. It also showed that the knowledge levels of the fourth year nursing students were average, but that their protective behavior was very insufficient. These findings suggest that it is of extreme importance to acquire knowledge and behavior for protection against skin cancers in the education of nursing students. Key words: nursing student, skin cancer, sun protection.
INTRODUCTION Skin cancer is a major health problem (Healthy People 2020 Guidelines; Mahon & Yackzan, 2010). Today,
Correspondence: Medine Yilmaz, Department of Public Health Nursing, Faculty of Health Sciences, Izmir Katip Celebi University, Balatcik Campus, 35620, Çig˘li, Izmir, Turkey. Email: [email protected] Received 10 September 2013; accepted 4 February 2014.
people are exposed more to intensive ultraviolet (UV) rays than in the past with the popularity of tanning in recent years; people spend an excessive amount of time under the sun during seaside vacations and in participating in outdoor sports; new technology has meant an increase in industrial equipment emitting UV rays; and the hole in the protective ozone layer has increased in size. This increased exposure to UV radiation may be one of the biggest factors contributing to the rise in the incidence of skin cancer (Mahon & Yackzan, 2010).
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Studies have been made in many countries to determine the effect of the sun’s rays on the skin in various segments of society, the levels of knowledge and awareness on the subject of skin cancers, and behavior for protection against the sun (Nikolaou et al., 2009; Saridi et al., 2009; Stanton, Janda, Baade, & Anderson, 2004). Furthermore, many types of media and educational campaigns have been carried out with the objective of preventing the development of skin cancers (Geller et al., 2002; Saraiya et al., 2003; Vries, Lezwijn, Hol & Honing 2005). Primary and secondary prevention are essential components of the effort to decrease mortality and morbidity risk from these malignancies. The total of all skin cancers can be decreased by 80% with suitable protective measures taken from an early age (Saraiya et al., 2003). The Healthy People 2020 Guidelines aims to “increase the proportion of persons who participate in behaviors that reduce their exposure to harmful ultraviolet (UV) irradiation and avoid sunburn”. The Healthy People 2020 Guidelines pointed to an increase in the proportion of people using skin cancer primary prevention strategies, which include at least one of the following protective measures: avoiding the sun between 10.00 and 16.00 hours, wearing sun-protective clothing, using sunscreen with a sun protection factor (SPF) of 15 or higher, and decreasing or avoiding UV radiation exposure (Healthy People 2020 Guidelines). Just as early detection of skin cancer and screening are important, taking individual protective measures are also extremely important (Mahon & Yackzan, 2010). The personalization of these measures according to age, sex, and educational status is important (Stanton et al., 2004). Intelligent strategies should be also developed for changing the belief and perception that having a tanned skin is desirable (Nikolaou et al., 2008; Saridi et al., 2009). Training individuals on protection against the harmful effects of the sun’s rays, changing stereotyped behavior, and transforming information into behavior are of extreme importance. Nurses can influence the public to practice primary and secondary prevention strategies (Mahon & Yackzan, 2010; Tidy, 2003). It is inevitable that nurses, who have an effective role in health protection, should also be included in education and campaigns against skin cancer. Therefore, acquiring the knowledge and skills to change behavior in relation to skin cancers is relevant to the education of nurses. In a Greek study including nurses, women were found to use sunglasses and sunscreen more than men and age was also found to affect the use of protective measures
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with those aged between 30 and 50 years found to use an umbrella/shade and clothing to protect themselves from sun exposure more than those younger than 30 years (Brokalaki et al., 2011). In other study (Ermertcan et al., 2005), use of sunscreen and sunglasses in men over 30–40 years of age were significantly higher in doctors and nurses (52.7% and 50.5%, respectively) than medical and nursing students. It was found that incomplete information about protective measures, especially using sunscreen and wearing protective clothing and a hat. Ermertcan et al. (2005) suggest that an efficient policy of education on the effective use of sun protection methods beginning in childhood and adolescence should be developed to prevent skin cancer. The Aegean Region of Turkey has a typical sunny Mediterranean climate. This region benefits greatly from the sun and is exposed to sunlight for 9 months a year. Consequently, it is important to determine the knowledge levels and protective behavior against the effects of the sun and protection against skin cancers of nursing students born or living in this region. The objective of this study was to determine the skin cancer knowledge and sun protection behavior among nursing students. In accordance with this objective, the study questions directed to the first and fourth year university students were as follows: 1 Is there a difference between the groups (first and fourth year nursing students) in their knowledge level scores for protection against the sun and skin cancer? 2 Is there a difference between the groups in their protective behavior scores for protection against the sun and skin cancer?
METHODS Sample and setting This descriptive study was carried out between September 2012 and February 2013. In Turkey, nursing schools are faculties directly connected to a university. Nursing education involves a 4 year (eight semester) bachelor degree program in a university. Each semester, the students register in one main professional nursing course and in the second semester they attend a clinical practice course in addition to their theoretical courses. The research was conducted among students of eight nursing colleges in cities in the Aegean Region of Turkey (n = 1625). No sampling method was used in the study, because the study included the whole adolescent and youth population of the selected university (n = 1178) (Table 1). The ratio of participation was 72.8% for the first year students and 72.1% for the fourth year
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
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Table 1 Name, location of nursing school and number of students in Aegean Region University
Location
Grade 1
Grade 4
City Urban Urban Urban Urban Urban City City
99 101 108 96 51 104 49 68 676
65 80 87 48 26 96 44 56 502
Denizli Manisa Kütahya Us¸ak Afyon Mug˘la Aydin I˙zmir Total
Pilot application in 20 nursing students June 2012 Data collection September 2012–February 2013 Universe 1625 students (Total eight school of nursing in Agean Region) Inclusion criteria Willingness of students - Attainability to students Sample 1178 students (The rate of participation) 1st Grade d 676 students
4th Grade 502 students
Questionnaire Q (Sociodemographic characteristics, Knowledge and Behavior Questions)
Figure 1 Design of study.
students. The criteria for inclusion were being a university student of the nursing and being willing to take part in the study (Fig. 1). The majority of students (37.4%) were born in a city in the Aegean Region, 14.8% in the Mediterranean Region and 14.4% in the Black Sea Region.
Data collection The data were collected by the researchers between September and December in the academic year 2012–2013. They were contacted directly in their classroom. Detailed information was given to the students about the research and verbal consent was obtained. The ques-
tionnaires were distributed to students in their classroom. It took approximately 20 min to fill out a survey in a single session. After the students filled out the questionnaires in the classroom, the questionnaires were collected by researchers in a box.
Instruments The survey instrument was a questionnaire developed to determine knowledge and behavior, and was based on the current published work (Brokalaki et al., 2011; Devos, Baeyens, & Van Hecke, 2003; Ermertcan et al., 2005; Hedges & Scriveni, 2010; Miles, Waller, Hiom, & Swanston, 2005; Nikolaou et al., 2009; Saridi et al., 2009; Stanton et al., 2004). After determining the questions, the expert opinions of one dermatologist, three academician nurses and two dermatology nurses were obtained. In June 2012, subsequently, a pilot application was conducted with 20 young nursing students of the same age who were not participating in the study. The final questionnaire included four parts, with 17 questions relating to sociodemographic characteristics, 10 questions about behavior for protection against the sun, 14 questions relating to the risk factors of skin cancer, and 18 questions about knowledge of skin cancers and methods of protecting against the sun. In addition, questions were asked about familial skin cancer, experiences of sunburn, sources of knowledge, tanning behavior and use of SPF. The skin types of the students were grouped according to the Fitzpatrick classification: skin “burns” without or with minimal tanning (phototype I and II), “burns” and then tans (phototype III) or tans easily without burning (phototype IV) (Nikolaou et al., 2009).
Knowledge level score for protection against skin cancer The knowledge level for the etiopathogenesis of skin cancers and methods of protection against the sun was examined in 15 questions and the results were obtained by adding 1 point for each of the correct responses (0 points were given for “wrong/I do not know” answers and 1 point was given for correct answers). The knowledge level score was formed by adding all the scores together. The knowledge scores ranged 0 (minimum) to 15 (maximum).
Behavior score for protection against the sun and skin cancer Points were given according to the frequency of implementation of each of the methods applied for protection
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Permission was obtained from the ethics committee of the university (ethic no: 26) where the research coordinatorship was located in order to carry out the study. Verbal permission was obtained from the nursing universities where the study was carried out and verbal approval was obtained from the students. Students’ names were not used.
anova – were used, in addition to descriptive statistics given in numbers and percentages. Number and percentage distributions of the sociodemographic characteristics of the students and the frequencies of protective practices were compiled. In the determination of the average scores for protective behavior, the responses of the students for each item were rated in the form of “always”, “frequently”, “sometimes/rarely” and “never” and were evaluated between 1 and 4 points. When a student’s score approached 4, it was interpreted that protective measures were being taken, and when it approached 1, it was interpreted that protective measures were not being taken. In addition, a relationship was sought between the sociodemographic variables of the students and their scores for protective behavior, knowledge levels and risk factors. Cronbach’s alpha was 0.72 (moderate = 0.60–0.80) (Ozdamar, 2002).
Statistical analysis
FINDINGS
against the sun and were evaluated on a 4 point scale (“never” = 1, “sometimes” = 2, “frequently” = 3 and “always” = 4). The total points obtained were divided by the number of 13 items, to calculate the behavior score for protection against the sun and skin cancer. For the calculation of the total score, a minimum of eight responses to the 13 protective behavior patterns was needed (minimum 13, maximum 52 points).
Ethical implementations
The data were evaluated with IBM Predictive Analytics SoftWare (PASW) Statistical Product and Service Solutions (SPSS, Chicago, IL, USA) version 20.0. In the evaluation of the data obtained in the study, statistical significance tests – non-parametrical tests such as the χ2-test, standard deviation, Student’s t-test and one-way
Demographics and skin characteristics The sociodemographic characteristics of the students are given in Table 2. A majority of both the first year and fourth year students were female (first year, 78.6%; fourth year, 54.1%). The students were mostly fair
Table 2 Sociodemographic characteristics of nursing university students and their risk factors for skin cancer Characteristics Mean age, years Sex Female Male Color of skin Light-skinned Fair-skinned Dark-skinned Photo type I–II III–IV Color of hair Blonde–auburn Dark brown/black Common nevi I have never counted ≤5 6–10 11–20 >20 Total †
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Grade 1
Grade 4
χ2
P
5.04
0.002
19.2 ± 1.2 n %† 531 78.6 145 21.4
n 366 136
22.4 ± 1.4 %† 54.1 45.9
474 371 202
15.2 54.9 29.9
87 294 121
17.3 58.6 24.1
4.98
0.83
424 252
62.7 37.3
307 195
61.2 38.9
9.72
0.008
220 456
32.5 67.5
188 314
37.5 62.5
3.06
0.80
351 124 60 65 76 676
52.0 18.3 8.9 9.6 11.2 57.4
225 96 63 52 66 502
44.8 19.1 12.5 10.4 13.2 42.6
7.81
0.09
The percentage of rows.
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
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Table 3 Distribution of nursing students’ knowledge about sun protection and skin cancer prevention Grade 1 Characteristics
n
Knowledge status of skin cancer Do not know 402 Know 274 Knowledge of protection from skin cancer Do not know 187 Yes, I know 102 I know a bit 387 Perception of skin cancer risk in future High 29 Moderate 113 At average 257 I do not know 277 Source of information† From the lessons 92 From the clinical practice course 46 From the health profession 26 From the media (e.g. Internet, TV) 175 From family or friends 83 †
Grade 4
%
n
%
χ2
p
59.5 40.5
170 332
33.9 66.1
75.59
0.000
27.7 15.1 57.2
76 169 257
15.1 33.7 51.2
65.38
0.000
4.3 16.7 38.0 41.0
23 110 211 158
4.6 21.9 42.0 31.5
12.37
0.006
13.6 6.8 3.8 25.9 12.3
233 94 57 269 61
46.4 18.7 11.3 53.6 12.1
There is possibility of marking multiple choices in this question.
skinned (first year, 54.9%; fourth year, 58.6%) and had dark brown or black hair (first year, 67.5%; fourth year, 62.5%). The proportion of phototype I–II in the first year students was higher than in the fourth year students (χ2 = 9.72, P = 0.008). A large proportion of the students in both years (first year, 52%; fourth year, 44.8%) did not know the number of moles on their bodies (Table 2).
Knowledge level for protection against the sun and skin cancer It was determined that 59.5% of the first year students did not know about skin cancers but that 66.1% of the fourth year students knew about skin cancers (χ2 = 75.59, P = 0.000) (Table 3). It was found that the first three sources of knowledge for the first year students were media tools at 25.9%, lessons at 13.6% and friends and family at 12.3%, while for the fourth year students the first three sources of knowledge were media tools at 53.6%, lessons at 46.4% and clinical practice course at 18.7% (Table 3). It was determined that in answer to the question about knowing how to protect against skin cancer, 57.2% of the first year students responded “I know a bit”, 51.2% of the fourth year students responded “I know a bit” and 33.7%
responded “Yes, I know”; and there was a significant difference between the two groups in knowing how to protect against skin cancer (χ2 = 65.38, P = 0.000) (Table 3). For perceiving the risk of having skin cancer in the future, 41% of the first year students stated “I do not know”. The response of the fourth year students was average or less than average at 31.5%. A statistically significant difference was determined for perceiving risk between the two groups (χ2 = 12.37; P = 0.006) (Table 3). It was observed that the average scores for knowledge (t = 10.13, P = 0.000) and behavior (t = 4.48, P = 0.000) for protection against the sun and skin cancer of the fourth year students (knowledge, 7.6 ± 2.9; behavior, 9.4 ± 2.8) were higher than those of the first year students (knowledge, 2.5 ± 0.4; behavior, 2.6 ± 0.4). A statistically significant difference was determined between the average scores of the two groups (Table 4).
Behavior for protection against the sun and skin cancer It was determined that 64.4% of the first year students sunbathed more in the noon hours, compared to 35.6%
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Table 4 Distribution of students’ mean scores of knowledge, behavior and attitude about sun protection and skin cancer prevention Scores Knowledge (15 questions) Behaviors (13 questions)† †
Grade 1, n/% 676 676
Grade 4, n/%
7.6 ± 2.9 2.5 ± 0.4
502 502
9.4 ± 2.8 2.6 ± 0.4
t
P
10.13 4.48
0.000 0.000
1 = never, 4 = always.
Table 5 Distribution of nursing university students’ behavior about sun protection Characteristics
Grade 1, n/%
χ2
P
44.2 35.6
5.38
0.02
66.1 33.9
0.19
0.66
15.3 32.4 15.9 36.5
8.53
0.03
57.4 42.6
2.72
0.09
36.0 64.0
2.27
0.13
84.9 15.1
1.60
0.20
Grade 4, n/%
Sunbathing in noon hours No 535 55.8 424 Yes 141 64.4 78 Tanning No 458 67.7 332 Yes 218 32.3 170 Sunbathing time (n = 218) Day long 33 15.1 26 09.00–11.00 hours 55 25.2 55 11.00–16.00 hours 61 28.0 27 After 16.00 hours 69 31.7 62 Use of sun-protective factors No 420 62.1 288 Yes (>15 SPF) 256 37.9 214 Experience of slight sunburn (in their lifetime) Never 273 40.4 181 Minimum, once 403 59.6 321 Experience of 3–4 degree sunburn (in their lifetime) Never 591 87.4 426 Minimum, once 85 12.6 76 SPF, skin protection factor.
of the fourth year students (χ2 = 5.38, P = 0.02). It was observed that 32.3% of the first year students and 33.9% of the fourth year students sunbathed to get a tan, and that the first year students did this mostly between 11.00 and 16.00 hours and after 16.00 hours, while the fourth year students sunbathed to get a tan between 09.00 and 11.00 hours and after 16.00 hours (χ2 = 8.53, P = 0.03). A large proportion of the students in both years of study did not use sun protectors (first year, 62.1%; fourth year, 57.4%) and it was observed that the difference between the two groups was not significant (P > 0.05) (Table 5). A total of 59.6% of the first year students and 64% of the fourth year students had experienced slight sunburn at least once and 13.8% (first year 12.6%, fourth year 15.1%) had experienced third to fourth degree sunburn at least once (P > 0.05) (Table 5). The fourth year students used sunglasses at a higher ratio (χ2 = 8.89, P = 0.03). Other than this,
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no statistically significant difference was determined between the two groups for protective behavior (P > 0.05) (Table 6). The genetic characteristics and knowledge, behavior, and attitude scores of all students were examined. It was found that light-skinned students showed more protective behavior than those with dark skins (2.65 ± 0.49 and 2.15 ± 0.52, respectively) (F = 6.19, P = 0.000), and that their scores on knowledge of protection against the sun were higher (8.77 ± 3.0 and 8.07 ± 3.0, respectively) (F = 3.55, P = 0.000). Similarly, it was found that those of phototype I/II (light-skinned) (I, 2.65 ± 0.4; II, 2.55 ± 0.4) showed greater protective behavior than those of phototype III/IV (dark-skinned) (I, 2.58 ± 0.4; II, 2.41 ± 0.4) (F = 6.01, P = 0.00). It was observed that those with light hair showed more protective behavior (light hair, 2.63 ± 0.4; dark brown, 2.58 ± 0.4; black, 2.46 ± 0.4) (F = 11.45, P = 0.000), and that their
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
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Table 6 Distribution of nursing university students’ behavior about sun protection and skin cancer prevention Protective behavior Using a cap Staying in the shade Use of sunglasses Tanning at the beach Using an umbrella Clothing, long-sleeves †
Grade
Never, n (%)†
Occasionally, n (%)†
Often, n (%)†
Always, n (%)†
1 4 1 4 1 4 1 4 1 4 1 4
422 (62.4) 317 (63.1) 27 (4.0) 12 (2.4) 225 (33.3) 146 (29.1) 352 (52.1) 251 (51.0) 484 (71.6) 344 (68.5) 140 (20.7) 90 (17.9)
213 (31.5) 119 (27.7) 99 (14.6) 63 (12.5) 231 (34.2) 154 (30.7) 179 (26.5) 129 (25.7) 107 (15.8) 8 (17.5) 329 (48.7) 244 (48.6)
24 (3.6) 33 (6.6) 281 (41.6) 231 (46.0) 142 (21.0) 119 (23.7) 63 (9.3) 61 (12.2) 50 (7.4) 45 (9.0) 100 (14.8) 86 (17.1)
17 (2.5) 13 (2.6) 269 (39.8) 196 (39.0) 78 (11.5) 83 (16.5) 82 (12.2) 61 (12.1) 35 (5.2) 25 (5.0) 106 (15.8) 82 (16.3)
χ2
P
6.87
0.07
4.50
0.21
8.89
0.03
2.50
0.47
1.79
0.61
2.31
0.67
Percentage of rows.
knowledge scores were higher (light hair, 8.72 ± 3.1; dark brown, 8.45 ± 2,9; black, 8.01 ± 3.1) (F = 6.42, P = 0.002).
DISCUSSION The main known cause of skin cancers is exposure to sunlight. Turkey is a Mediterranean country located between the temperate zone and subtropical zone and is a country with abundant sunlight. Despite this intensive exposure to the sun’s rays, there are still no societal initiatives for protection against the effects on health of the sun and against skin cancers, such as exist in the other European countries (Geller et al., 2002; Saraiya et al., 2003; Vries, de Lezwijn, Hol, & Honing, 2005). Not much is known, however, about the behavior, attitude, and perceptions of adolescents and young people on the subject of exposure to the sun and its associated risks. This study has shown the need for eliminating the lack of knowledge on protection against skin cancers in the curricula as a course in one semester or to take place in the lessons of nursing students, who will be responsible for the care of individuals in the society in the future, and the need for giving more place in education to the skills of acquiring protective attitudes and behavior such as wearing sun-protective clothing and sunglasses, and using sunscreen with an SPF. Phenotypic individual risk factors, such as hair, skin and eye color, are directly related to sensitivity to UV radiation. Persons with a light or fair complexion have a tendency to freckle or burn easily and are at higher risk (Brokalaki et al., 2011; Mahon & Yackzan, 2010; Nikolaou et al., 2009). A large proportion of the students in the study had dark brown or black hair. This is
an advantage against the effects of sunlight. Nevertheless, the first year students were mainly light-skinned (phototype I–II), which shows that this group had a greater risk. Widespread exposure to the sun causes an increase in moles, and the number of melanocytic moles is correlated with risk (Mahon & Yackzan, 2010). It was observed that a large proportion of the students in both years did not know the number of moles on their bodies and did not perform self-examination for the early determination of skin cancers. In other studies, just as in this study, it was determined that nurses (Brokalaki et al., 2011) and adolescents (Saridi et al., 2009) had similar numbers of moles and did not self-examine their moles. If skin cancer is detected early, its treatment is facilitated. Therefore, personal skin examination is important for early diagnosis (Tidy, 2003). It is important to acquire the skill of self-examination in future training activities for adolescents and young people. It has been reported in other studies that protection is of primary importance for decreasing the exposure to the major risk factors for skin cancers. One of the key preventive measures is to stay in the shade during the peak hours of the day (Mahon & Yackzan, 2010; Saraiya et al., 2003). The present study draws attention to the fact that approximately one third of the students in both years sunbathed to get a tan. Besides, the first year students preferred to sunbathe between 10.00 and 16.00 hours and showed riskier behavior. In fact, in studies made with different samplings (Brokalaki et al., 2011; Nikolaou et al., 2009; Saridi et al., 2009), it was observed that individuals also sunbathed at risky hours and that the incidence of sunbathing was similar or even higher.
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
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Those who experience a serious degree of sunburn before the age of 18 years at risk of developing melanoma, which is the most serious cancer type (Saridi et al., 2009). According to the conclusion of one study, the belief that it is necessary to burn to get a tan prevents the use of protection, and this also coincides with more frequent sunburns (Geller et al., 2002). That the fourth year students experienced slight and severe sunburn at a higher rate than the first year students shows that this group was exposed to greater risk. The ratio of sunburn experiences of the students in both groups are close to the results in various other studies (Geller et al., 2002; Vries et al., 2005) and are higher than in some others (Brokalaki et al., 2011; Turgay, Sari, Can, & Ekti Genc, 2005). The Healthy People 2020 Guidelines has announced the aim of increasing the proportion of adults aged 18 years and older who follow protective measures to reduce the risk of skin cancer (Healthy People 2020 Guidelines). The three methods of protection implemented the most frequently are staying in the shade (Brokalaki et al., 2011; Devos et al., 2003; Ermertcan et al., 2005; Uslu, Karaman, Savk, & Sendur, 2006; Vries et al., 2005), the use of protective clothing (Devos et al., 2003; Vries et al., 2005) and the use of sunglasses (Brokalaki et al., 2011; Ermertcan et al., 2005; Uslu et al., 2006). Just as in another study made in Turkey (Ermertcan et al., 2005), this study showed that the risk of sun exposure is largely unrecognized in the Aegean Region of Turkey, and nursing students have very inadequate information and behavior concerning protective measures. The use of sun protection in the students in both years was very low. While this result was similar to the results of some studies (Devos et al., 2003; Ermertcan et al., 2005; Geller et al., 2002; Saridi et al., 2009; Spradlin, Bass, Hyman, & Rosanne, 2010), it was low compared to studies conducted in Greece (90%) (Nikolaou et al., 2009) and Malta (51%) (Scerri, Aquilina, Amato, & Dalmas, 2002). Other than the fourth year students using sunglasses more, the protective measures in both groups were very insufficient, and no difference was observed between the two groups of students. In a study conducted on persons between the ages of 16 and 65 years, it was determined that the use of protection and general protective behavior were the lowest in persons between 16 and 24 years of age (Weinstock, Rossi, Redding & Maddock, 2000). Geller et al. (2002) reported an increase in behavior for protection against the sun in students between 15 and 18 years of age when the topic of skin cancer was added to school curricula. In Turkey, there is no formal lesson
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on the curriculum of nursing schools on health protection and development, and is generally given little coverage in the content of lessons on protection from cancer. Teaching protective measures should be given to students in a lesson including health promotion issues such as cancer epidemiology, health promotion strategies, early diagnosis and medical–surgical nursing from the first grade to fourth grade. These educational sessions should be given by interactive methods to increase awareness. It must be determined whether behaviors change by long-term follow up. If behavior change has not occurred during this process in students at risk, counseling should be given to take individual protective measures. Some messages can be specifically targeted at students at risk. If these messages are given by peers, it can have a positive influence on an student’s sun safety habits. In studies made in various countries (Hedges & Scriveni, 2010; Miles et al., 2005), it was reported that the knowledge of participants of the risks of exposure to sunlight and of protective measures was at a medium to high level. In the present study, half or more than half of the students in both years did not know the types of skin cancer and how to protect against them. In a study conducted in Greece (Nikolaou et al., 2009), it was determined that a majority of the participants knew that exposure to the sun was a cause of skin cancer, but that this was not known by those younger than 34 years of age. It was reported that Greek adolescents between 15 and 18 years of age (Saridi et al., 2009) had both insufficient knowledge and also displayed risky behavior during the summer months. In this study, despite the fact that the average knowledge scores of the fourth year students were higher than those of the first year students, if it is considered that the students at this year level have received professional education, then it can be stated that their levels of knowledge and ratios of showing protective behavior were very low. This conclusion shows that besides adding knowledge to nursing education curricula, the need for acquisition of positive behavioral changes must be addressed. In the future, comprehensive studies can be designed. Studies made in various countries (Hedges & Scriveni, 2010; Saridi et al., 2009) show that television and family are the most important sources of knowledge and, in fact, for the students in this study, media tools (Internet, newspapers, TV) were in first place. The fact that the media was used frequently as a source of knowledge in both groups shows that it is an effective tool in reaching all segments of society with awareness and educational campaigns. Nevertheless, it is thought-
© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
Japan Journal of Nursing Science (2015) 12, 69–78
provoking that the level of the use of classes and professional practice as a source of knowledge by fourth year students throughout their university education was very low. A differentiation was observed between the first and fourth year students on the perception of the risk of skin cancer in the future. While the first year students did not know the risk (41%), the fourth year students saw it as a less than average risk (42%). It has been reported that those who consider themselves at risk for skin cancer and those who have skin which is sensitive to the sun take more protective measures against exposure to sunlight (Abroms, Jorgensen, Sothwell, Geller, & Emmons, 2003). Studies by Stanton et al. (2004) and Vries et al. (2005) show that those who consider themselves to be at risk use more protective measures. However, it was found in this study that protective behavior and knowledge levels about skin cancer in students who did not see themselves as being at risk of skin cancer in the future was low, and that there was no relationship between those who considered themselves to be at high risk and the use of protective measures. It was also observed that the use of protective measures was also slight in those who did not foresee or did not know the risk. According to a study by Fangchao, Collado-Mesa, Hu, Kirsner (2007), it can be stated that the perception of the risk of skin cancer in Turkish adolescents and young people is lower than the risk perception of people in other countries. There were some limitations of this study. The moles were not counted by a health professional and the numbers were recorded according to the student’s memory. Another limitation is that the students answered “I know” or “I do not know” with a statement about skin cancer, a fact lead to an overestimation of the proportion of students who have a true knowledge of skin cancer. The study population was nonrandomized. Finally, the sample included only nursing students in the Aegean Region of Turkey. Studies should be carried out to show data for all Turkey’s regions’ nursing students.
CONCLUSION The conclusion of this study revealed that the knowledge levels and protective behavior of first year university students against the harmful effects of the sun and for protection against skin cancer were alarmingly low. Additionally, it also showed that the knowledge levels of the fourth year university students were average, but that their protective behavior was very insufficient. Con-
Skin cancer and nursing students
sequently, it is of extreme importance to acquire knowledge and behavior about the harmful effects of the sun, and for the education of nursing students in protection against skin cancer, who will act as role models and who will take an active role in the protection and maintenance of the health of individuals. To make the Healthy People 2020 Guidelines into a reality, increased efforts to implement primary, secondary and tertiary skin cancer prevention are needed. Sun-safe behavior should be greatly encouraged. Implementation for developing competent nursing graduates should be strengthened. Finally, faculty development and integration of clinical practice guideline to the schools program of study may be warranted. Putting educational programs into practice will help to decrease the risk of skin cancers in children and young people in the future and contribute to the acquisition of protective behavior and attitudes.
CONFLICT OF INTEREST No conflict of interest has been declared by the authors.
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© 2014 The Authors Japan Journal of Nursing Science © 2014 Japan Academy of Nursing Science
